For various reasons, patients seek care at different hospitals within a region, resulting in fragmented medical records at the point of care. In the emergency department, this is a particularly important issue because the emergency department provides open access to all patients and requires rapid high-stakes decision making to function well. To address these issues and as a result of federal initiatives, health information exchanges (HIEs) have been designed and implemented in various regions throughout the United States to promote health information sharing. The use of HIEs has been demonstrated to lower costs and avoid duplicative testing and treatment; however, obstacles such as physician usage characteristics and institutional concerns regarding information sharing exist and must be addressed before full implementation and adoption of HIEs among institutions take place. Further research is needed to describe the benefits of HIEs and how they can affect these barriers.

Urinary catheterization has risks and its use should be limited because it is the main cause of healthcare-associated urinary tract infection. Other risks are the potential for urethral injuries and the possibility that the catheter will be left in permanently. Rates of urinary catheterization in internal medicine departments generally range from 8% to 20%, with higher rates in older adult patients. Various attempts have been made to decrease catheterization rates with variable success. A major problem is that the guidelines and criteria for urinary catheterization are inconsistent and open to variable interpretations. More restrictive criteria based on observable patient benefit can reduce rates of urinary catheterization and may improve patient care.

Concerns have been raised about the safety and efficacy of blood transfusions. Blood products are in demand and a decreasing supply is projected, with resource conservation a global concern. A consultant group determined that the transfusion rate at Mease Countryside Hospital was higher than an average baseline.A process-improvement project was initiated using a multidisciplinary team approach to improve blood utilization and ensure appropriateness in transfusion practice. The foundation of this project was to create new guidelines for transfusion; provide detailed education, communication, reporting, and feedback; and develop criteria to ensure compliance.The mean monthly usage of red blood cell units per 1000 inpatient discharges between April 2010 and October 2011 was 321.4 compared with 212.0 for the 5 months after implementation. The mean monthly number of patients transfused per 1000 inpatient discharges from April 2010 to October 2011 was 135.2 compared with 90.2 after implementation. In both cases, this reduction was found to be statistically significant at a 95% confidence level (P = 0.000 in both respects).The success of this project was the result of careful planning and execution, administrative support, physician leadership, and teamwork. Blood management includes strategies to avoid inappropriate transfusions and proactively treat anemia. Anemia management should be based on the patient's symptoms, laboratory values, and clinical assessment. Treatment of anemia should encompass a patient-centered approach, with the aim of promoting patient safety and minimizing the risk from exposure to blood products.

As the population ages, octogenarians are becoming the fastest growing patient demographic for non-small-cell lung cancer. We examined lobectomies and 30-day outcomes in this group compared with younger patients to gain insight into the optimal treatment for this challenging group.We analyzed data from the American College of Surgeons National Quality Improvement Program for patients with lung cancer undergoing lobectomy during calendar years 2005-2010. We compared clinical risk factors, intraoperative factors, and 30-day operative mortality and major morbidity in octogenarians versus younger patients undergoing either open traditional thoracotomy (OPEN) or video-assisted (VATS) pulmonary lobar resection.Of 2171 patients who had lobar resections for lung cancer, 245 (11%) were octogenarians. Six hundred eight lobectomies (28.0%) were VATS procedures and 1563 (72.0%) were OPEN procedures. The VATS rate increased as patient age increased (34% VATS for octogenarians vs 27% for patients younger than 80 years; P = 0.01). Thoracic surgeons performed VATS with greater frequency compared with general surgeons, especially in octogenarians (41% VATS for thoracic surgeons vs 29% for general surgeons; P < 0.001). Univariate analysis suggests significantly increased major morbidity (pulmonary, renal, and sepsis), but not operative mortality in octogenarians; however, multivariate predictors of major morbidity include OPEN procedures, preoperative decreased functional status, history of chronic obstructive pulmonary disease, preoperative sepsis, prior radiation, diabetes, and dyspnea on exertion (all P < 0.05), but they do not include advanced age.Comorbidities predict most increased morbidity in octogenarians, and advanced age per se is not an important multivariate predictor of postoperative morbidity or mortality. The frequency of VATS lobectomy increased with increasing patient age, and VATS predisposes to decreased morbidity in octogenarians.

The purpose of this study is to describe the findings and patterns of injury on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) after whole-body hypothermia treatment for neonatal hypoxic ischemic encephalopathy.A retrospective review of consecutive term neonates treated with whole-body hypothermia was performed. Data recorded included demographics and MRI and MRS findings, and day of life (DOL) studies were performed. Injury patterns were classified on MRI as deep, cortical, mixed, or diffuse. The relative apparent diffusion coefficient (rADC) was plotted against DOL scanned and the presence of lactate was recorded.MRI was performed in 44 infants, 34 of whom also underwent MRS. MRI was abnormal in 32% of neonates, 29.5% of whom were imaged at DOL 4 to 8. rADC values were lowest in neonates scanned on DOL 4 and 5 and remained low up to DOL 8. The deep brain nuclei were involved in hypoxic ischemic encephalopathy in 93% of neonates with abnormal MRIs and lactate was identified on MRS in 18% of neonates between DOL 4 and 8.MRI performed after therapeutic cooling was abnormal in 29.5% of neonates scanned on DOL 4 to 8. Deep nuclear injury was identified in 93% of neonates. Lactate was present on MRS in 18% of neonates, and rADC values were most reduced on MRI between DOL 4 and 8.

The outpatient parenteral antibiotic therapy (OPAT) program of the Portland Veterans Affairs Medical Center (PVAMC), which has a self-administration model, is staffed by visiting nurses from a specialist infusion company. This study evaluates the clinical outcomes of these patients.This study was a retrospective chart review of 262 patients at PVAMC who had received OPAT between 2007 and 2009. Patients were included only if they received ongoing care at PVAMC. The data collected included conditions and organisms being treated and types and durations of antibiotics used. Clinical cure was defined as documented cure at the end of treatment and 90 days post-OPAT.One hundred ninety patients of 262 were analyzed. The mean age was 63.2 years. Diabetes was the main comorbid factor (17%). The most common indications for OPAT were osteomyelitis (38%), urinary tract infection (23%), and skin and soft tissue infection (12.6%). Mixed bacterial culture (26%) and Staphylococcus aureus (31%) were the most common organisms treated. Vancomycin was the most frequently used antibiotic (26%) followed by ceftriaxone (12%). The median duration of OPAT was 30 days. The rate of clinical cure at end of treatment observed for all infections treated was 78%, which then decreased to 58% at 90 days post-OPAT (P < 0.001). Patients with diabetes and osteomyelitis had an increased risk of relapse at 90 days post-OPAT on multivariate analysis (P = 0.025).An OPAT program using a self-administration model treating patients who were military veterans had successful outcomes. Patients with diabetes and osteomyelitis had worse clinical outcomes 90 days after the completion of OPAT therapy.